Lecture 13 - CNS, Head and Neck Infections PDF

Lecture 13 — CNS, Head and Neck infections Dr. Ed El Sayed NURS 342 Objectives Clinical presentation of CNS, head and neck infection Etiology Diagnosis Treatment Prognosis Most likely dx Best initial test Most accurate test What is the treatment I. CNS infections All central nervous system (CNS) inf...

Lecture 13 — CNS, Head and Neck infections Dr. Ed El Sayed NURS 342 Objectives Clinical presentation of CNS, head and neck infection Etiology Diagnosis Treatment Prognosis Most likely dx Best initial test Most accurate test What is the treatment I. CNS infections All central nervous system (CNS) infections can present with fever, headache, nausea and vomiting All CNS infections can lead to seizures I the know Loading… The major CNS infections we will study in this course: 1. Meningitis (bacterial, fungal, viral) 2. Encephalitis 3. Brain abscess 1. Meningitis any infection I Meningitis is an infection and inflammation of the covering (i.e. meninges) of the CNS (brain and spinal cord) ANY infection can lead to meningitis, but the most common are: m Streptococcus pneumoniae (majority of cases) Haemophilus influenzae (rare because of childhood vaccination) Niesseria meningitides (adolescents, often present with skin rash) ↓ Viral (dx of exclusion) etreme - Listeria monocytogenes (more common in elderly and neonates) Staphylococcus (mainly in patients who underwent recent neurosurgery) Cryptococcus (HIV/AIDS patient with CD4 count Diagnostic tests: Lumbar puncture (LP) is the best initial test AND most accurate test ↓ BUT LT Head CT is done before LP ONLY IF the 1st if patient presents with: lany of these symptoms) & seizures papilledema (blurred vision from increased intracranial pressure) focal neurological findings ( gait disturbance) confusion that interferes with the clinical examination - If LP cannot be performed immediately, you must give antibiotics while waiting for head CT to prevent irreversible brain damage emper Lumbar puncture progression on comorbidities is bacteria eth depends - resistant * Immunocompromised ↓ CD1 treat allergey blu still need to take cettriaxone (B-lactam) - Symptoms If Neisseria is present, additional measures need to be taken: Patient must be placed in droplet isolation > - who do you share saliva / (kiss , sex, ete. for & leas)- zu his All close contacts must be given oral rifampin as prophylaxis even if they are vaccinated againstneisseria meningitides) > - - - Meningococcal Vaccine There are three types: ACWY, MenB and Pentavalent I strain of basterin Meningococcal ACWY vaccine is recommended at age 11-12 - - - A booster dose of the ACWY is recommended at age 16-18 (because this is when there is heightened risk of infection — college, military, sex parties, etc) People who receive their first dose of the ACWY vaccine at or after age um 16 years do NOT need a booster dose - -Neisseria & - B strash Meningococcal vaccine B is NOT recommended for routine vaccine among N healthy persons (in other words, vaccine B is only for certain persons who have preexisting medical conditions that increases their risk for meningitis like -HIV, immune-modulator drugs, sickle cell disease, functional or anatomical men or there but does n not work aspelenia) Meningococcal Vaccine (cont.) The pentavalent vaccine combines all 5 strains (A/C/W/Y/B) Given to all people between the ages of 10-25 years Loading… Two shots (6 months apart) So… why not just use the pentavalent vaccine and ditch the other two? CO$T! 2. Encephalitis LP > - cardinal headache to Normal get - low back J & feature pain confusion - Infection and inflammation of the brain parenchyma (brain tissue) Usually viral (most common virus is HSV)= alpha Usually sudden onset and the most common clinical presentation is fever and confusion Best initial test is head CT — shows brain tissue damage (LP not done first because of the severe confusion) > - establish latences in Neurons - > ↓ - amplification Test Most accurate test is polymerase chain reaction (PCR) on CSF sample Serology (blood tests) is useless because majority of population will have antibodies against HSV activate by Kinasetarget inhibit - - But polymerase target > - of acyclovir Treatment is intravenous acyclovir (oral drugs like valacyclovir and famciclovir are ineffective) Resistant cases are treated with foscarnet (associated with renal toxicity Resistant cases are treated with foscarnet (associated with renal toxicity) HSV encephalitis ① 3. Brain abscess A brain abscess is a collection of infection within a localized brain tissue (parenchyma) Anything that causes bacteremia (e.g. pneumonia, endocarditis) can dislodge microbes into the brain cause abscess Brain abscess can also spread from sinus infections or otitis media Brain abscess is polymicrobial in nature (Gram negative/positive, aerobes/anaerobes) Without biopsy you will never be able to distinguish brain abscess from cancer The best initial test is CT or MRI The most accurate test is biopsy * LP is contraindicated (because of possible herniation) Adjusted according to lab results - Empiric treatment is with vancomycin + metronidazole + ceftriaxone (treatment is then adjusted according to lab results) Brain Abscess O II. Head and Neck Infections 1. Otitis media 2. Otitis externa 3. Sinusitis 4. Pharyngitis wood 1. Otitis Media T ox M Middle ear infection & also delt meningitis Streptococcus pneumoniae is the most common cause Clinical presentation includes fever, pain, ear “fullness” sensation, bulging and * immobility of the tympanic membrane (a fully mobile tympanic membrane essentially excludes otitis media) * - The most accurate test is tympanocenetsis to obtain a sample of the fluid accumulating on the tympanic membrane for culture and sensitivity — however, tympanocentesis is not routinely done because most otitis media cases will respond to empiric antibiotic therapy (in other words, tympanocentesis is reserved for recurrent or resistant cases) B-lactur - - ↓ uvieren Best initial treatment is amoxicillin (second line option is azithromycin) Emacrolide - 2. Otitis Externa Infection and inflammation of the external auditory canal Also known as “swimmer’s ear” because exposure to water raises the pH of the canal — good environment for staphylococcus Clinical presentation is usually itching, pus discharge and a tender tragus Empiric treatment is with topical neomycin/bacitracin combo or topical fluoroquinolone (oflaxacin) Recurrent or resistant cases require culture of the pus/discharge for tailored treatment Malignant or “necrotizing” otitis externa is a misnomer — this is actually osteomyelitis (bone infection) of the area of the skull near the auditory canal (this is a disaster!) E will die Malignant otitis externa is most commonly caused by pseudomonas and is an EMERGENCY (must obtain MRI of the=> base of the skull and treat with INTRAVENOUS antibiotics against Ceftazobine EPID/tazo genta pseudomonas) & Next best step carbapenems imipenen m , IV , , , 3. Sinusitis Infection and inflammation of the sinuses Clinical presentation is with facial tenderness, discolored nasal discharge, bad taste in mouth, headache and sometimes -fever In most cases, treatment is symptomatic with over the counter nasal decongestants and antipyretics - -- abt a week Prolonged cases may require antibiotics (amoxicillin) and intranasal steroids Sinus biopsy is reserved for recurrent or resistant cases mm 4. Pharyngitis Commonly known as “sore throat” The most common cause among all age groups is· viral and the most common symptom is pain on swallowing - - n If the clinical presentation includes enlarged lymph nodes in the neck, fever, and exudate from pharynx, the likelihood of-streptococcus pharyngitis exceeds 90% - - - The “rapid strep test” is the best initial diagnostic test to detect group A beta-hemolytic streptococcus - -- > -- If there No is it Phargusitis NO COUGH and NO HOARSENESS Gram stain of the throat is NEVER the correct answer — everyone has bacteria in their mouths and throats! Best initial treatment is amoxicillin - - is Test Your Knowledge! Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 1. What is the most likely diagnosis? meningitil & Rasht teen tr Neisserin Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 2. What is the best next step in the management? A. Head CT scan B. Lumbar puncture C. Empiric IV antibiotics D. Observation must start before sending to CT Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 3. Should the patient be placed in isolation? A. Yes Droplet At least B. No laks 4 feet) 24 his Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 3. What type of isolation should be implemented? A. Standard B. Contact C. Respiratory D. Droplet Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 4. How long should the patient be in isolation? A. 24 hours B. 48 hours C. 72 hours D. Until antibiotics are stopped Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 5. What should this patient be tested for if he experiences multiple disease recurrence? A. HIV B. Neutrophil count levels C. ↓ C5-C9 complements (termina complement deficiency) D. Psychiatric disorders Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. Loading… 6. What additional measures should be taken at this time? prophes12x's Antibiotis (Ritapl) Case 1 A 19-year-old male is brought to the ER by his girlfriend. She tells you he started having seizures while they were making out. His family arrives and assures you their son was healthy all his life. The patient has a severe headache and upon physical examination he is confused, febrile, has a stiff neck and petechial rash on his torso. His blood pressure is 140/100 mmHg and heart rate is 60 bpm. His respiratory rate is irregular. 6. What if the girlfriend is pregnant? ceftriaxone toxi in us Vitampin pregnancy) Case 2 A 54-year-old man diagnosed with HIV 20-years ago presents to the ER with fever, stiff neck and photophobia. He is not confused and there are no signs or symptoms of focal neurologic deficits. LP is obtained for CSF analysis and empiric therapy with vancomycin + ceftriaxone + steroids is started. CSF results are shown. What is the best next step in management? A. Switch to amphotericin B + flucytosine B. Add ampicillin C. Continue empiric treatment individual presentation D. Switch to acyclovir trumps risk factor Test Value WBC count 3,200 neutrophils CD4 count 770 cells/cc Glucose Low Protein High Case 2 A 54-year-old man diagnosed with HIV 20-years ago presents to the ER with fever, stiff neck and photophobia. He is not confused and there are no signs or symptoms of focal neurologic deficits. LP is obtained for CSF analysis and empiric therapy with vancomycin + ceftriaxone + steroids is started. CSF results are shown. What is the best next step in management? A. Switch to amphotericin B + flucytosine B. Add ampicillin C. Continue empiric treatment D. Switch to acyclovir Test Value WBC count 3,200 neutrophils CD4 count 770 cells/cc Glucose Low Protein High Case 2 A 54-year-old man diagnosed with HIV 20-years ago presents to the ER with fever, stiff neck and photophobia. He is not confused and there are no signs or symptoms of focal neurologic deficits. LP is obtained for CSF analysis and empiric therapy with vancomycin + ceftriaxone + steroids is started. CSF results are shown. What is the best next step in management? A. Switch to amphotericin B + flucytosine B. Add ampicillin C. Continue empiric treatment D. Switch to acyclovir Test Value WBC count 3,200 neutrophils CD4 count 770 cells/cc Glucose Low Protein High